No News is Good News

I have been absent for more than a year while the office was under construction, but I have not forgotten my BlogFriends!  It is good to be back. 

I am now in a new phase of nursing, having attained the exquisitely harrowing position of RN Case Manager.  I manage up to 30 patients at a time, usually working with a Bluetooth and WiFi from the front seat of our trusty Dodge.  So far the only drawback has been occasional loneliness, but then the patient mix changes and suddenly there are more in-town patients.  Who has a chance to get lonely when there are only 10 road minutes between visits?  I have Mr Prattle this month, too, and my ears are bent flat to my head when I come out of there.  (I didn't think anyone could babble nonstop for an hour like that.)  Meanwhile, back at the office we have new students, which I love. 

The summer so far has been hot, humid, and very wet; I count myself fortunate that I have not yet driven into a sinkhole or been covered by a landslide.  The rain has been good for the garden, but on the other side of the house we are growing a crop of kamikaze bamboo which threatens to grow thick and wide enough to enshroud the entire house. On my days off I am losing the Bamboo Battle...or perhaps I am just bamboozled.

O Brother, Where Goest Thou?

Have you ever assessed a patient, weighing in your mind the number of  co-morbidities present and their severity, and realized with a jolt that if things don't change right sharpish, your patient will be a former patient?

On a Christmas weekend many years ago, I stood by  Eric's hospital bed.  He liked his room dark, lit with only a nightlight after 11pm so I did not snap on the overhead light.  That night the room was suffused with a glow from a miniature Christmas tree hung with tiny packages and ribbons.  From beneath a plaid blanket brought from home, Eric watched me approach with several syringes and alcohol wipes.  Where once we had joked and talked about his tv programs, tonight he managed only a wan smile of recognition.  

Eric was no older than 30; he had once had a profession but gave it up as the illness made simply getting out of bed an ordeal.  He had an intestinal condition...nausea & vomiting...weight loss...inability to gain a meaningful amount of weight...intractable pain...and insomnia.  His diagnosis didn't seem (to me or anyone else) sufficiently grave to cause a young person to waste away before our eyes.   

This condition waxed and waned over the course of five years.  He was hospitalized when the pain became too much to bear or he was unable to keep down any food.  Once he came in with a brisk GI bleed and passed frank blood for days.  Each time he was discharged he recovered, but never fully; then would come a relapse.  

He was not a favorite Frequent Flier.  Some of the staff disliked his continual demands for narcotic pain meds, coupled with whatever anti-nausea drug and sedative the doctors ordered, as often as he could get it.  He was a timekeeper, knew exactly when the stuff was due.  It was seldom enough to allow him a full night's sleep or full relief from pain and nausea. 

As my eyes adjusted to the low light this Christmas night, he threw back the coverlet, revealing a shockingly emaciated body.  I came to an abrupt and horrifying reality; he was back again, no improvement, back on mega narcotics, still insomniac, no definitive diagnosis.  Where are you going with this? I asked myself.  I have learned since to be wary of the question.  
 
To be privy to the end of human life, whenever it presents itself, is a burden and an honor. Most of the patients know their time is short.  Yet some people go along with the flow of their disease process without understanding what is going on or how serious their illness has become.  Think of COPD patients who leave the hospital and continue smoking, or diabetics with every -opathy possible who will not control their diets, check blood glucose only "when they think of it", and take their meds the same way. 

Silly of me to talk as if attention to regimen is the whole answer.  No one gets out of here alive, someone observed.  So it's true we are all on the same road to what we hope will be a good death in the end.  It is my hope for those I care for that they will become co-creators in their good death, not one day stunned to find themselves in line at the pearly gates.  

The discussion that follows the question, "Where are you going with this?" is not a comfortable one, which is why there are palliative care teams and hospices to guide the process.  Understanding that recovery is not possible allows room for other kinds of care just as important as vigorous treatment.  We got a note of thanks from the family of a patient who had gone to hospice.  The family had difficulty facing The Discussion, which they had to do in their parent's stead; dementia had left the parent sweetly senile.  The parent is at home under hospice care now, with less medical intervention (fewer needle sticks) and surrounded by loving family & staff.  Sometimes the hardest thing to do is the best for the patient.

We are not always talking about the end of life; we often need to teach cause-and-effect of a patient's condition and encourage him to take positive measures to keep whatever function he still has.  Some patients will take your information as gospel and they will recite it back to you with full compliance by the third visit.  Some only get it when they have had another  exacerbation...or three...or six.  
 
As a nurse develops a "spidey-sense" when things are not right, I hope the other sense is also allowed growing room, so that when a nurse sees signs of denial or end-of-life they are not afraid to begin the conversation.   I wish I had understood enough to sit down and talk with Eric that Christmas, for he was dead by the end of January.  "Where are you going with this?" may be one of the most important conversations your patient will ever have.

 

Thank you, Helen

I was at breakfast recently with Big Sweetie who was going on about people at the soup kitchen whose behavior is utterly annoying, and one in particular whose tolerance level is somewhere in the negative digits.  Sweetie was working himself up into a proper fit of indignation.  I fixed him with a critical stare and said, "Sounds like somebody needs to learn when to say 'Thank you, Helen.'"  Big Sweetie paused, then swiped half of my biscuit, lathered it with blackberry jam, and bit.  

While his mouth was full, I launched into a story.

Several millennia ago I was in nursing school.  We were the first graduating class in this particular school, and for our second year they added new instructors to the faculty, including Mrs. Willis who was to teach us psychiatric nursing.  She was an odd duck from the start; everyone agreed to this.  She was short and skinny with a pointy nose, cropped dark hair, and black-framed glasses that today would spell "geek".  She genuinely liked psych nursing.  She also had a way of evading questions that put the Gotta-Have-an-A students in a panic.  

Our class was nothing if not diverse.  There were among us women who were grandmothers, mothers, young marrieds, one just-out-of-high-school, and four men.  Adult students take college more seriously than do young people; add to that faculty who were learning to work together and an untried curriculum and you have more variables than an established nursing school presents.  It proved to be a learning experience for all.  

In those pre-NCLEX days, my adult classmates developed the habit of arguing every ambiguous answer.  One memorable test question involved a patient with hyponatremia, a term our instructors had not used, speaking instead of "low blood sodium."  I read the question, thought Na = sodium, so natremia must mean sodium in the blood, and answered the question accordingly.  (I think I answered wrong.)  The more vocal students ate up a good deal of class time protesting the test question because it used a term we had not been taught.  Ambiguous test questions like that one were thrown out with startling regularity.  

By the second year the faculty were not so easily argued down.

We waded through OB, successfully as it turned out, but we still had to pass psych in order to graduate.  Few of us looked forward to psych rotation, and the mental hospital where we were to be students looked like the set of One Flew Over the Cuckoo's Nest, which put us all on edge.  

In the classroom, Mrs Willis' lectures on psychiatric nursing further horrified us with talk of electroconvulsive therapy, masturbating patients, and four-point leather restraints.  Her peculiar sense of humor and often cryptic answers should have warned us.  I was not the only one counting the minutes until we could escape the whole psych nursing experience.  Mrs Willis finally finished lecturing; she grinned fiendishly when the A's asked her what to study for the test.  And then there was a memorable test.

38.  "Helen, a patient on the psychiatric unit, approaches you and hands you a shoe; the shoe is filled with feces.  Your response should be:

A. There is poop in this shoe, and it's unsanitary.  Did you wash your hands?

B. Tell me what this means, Helen.  Why are you giving this to me?

C. I am going to report you to the doctor.  Maybe you need a change of medication.

D. Thank you, Helen.

Imagine the furor in class as we corrected those questions!  Few of us answered correctly; I think I went for answer A.  The correct answer, Mrs Willis insisted, was D. Thank you, Helen.  Several A students gasped; the class all but collectively fainted.  We were still talking about it at year's end.  During the faculty roast we wished her a hearty handshake from a masturbating patient, and a shoe filled with shit.  She seemed pleased by our tribute.

Big Sweetie put down a rasher of bacon.  "You mean to tell me the correct answer really was supposed to be, Thank you, Helen?"  I assured him it was so. He shook his head.  

I continued, "You know, the more I work with people who are crazy or addicted or half-dead the more I learn about people who are not on the same leg of the journey as I am.  It seems to me the only thing we can say to some people is a simple acknowledgement that we don't get each other, but we're still cool. Thanks, Mrs Willis, for the insight.

In memoriam Mrs. Willis, wherever you are.  May your shoe be always full.

Lunchtime

It was past noon and I was driving like a native; that is, more or less down the middle of  a two-lane road, in a hurry to get down the mountain and on to my next patient.   I was also hungry; the hot tea and banana I'd had upon leaving the office had completely worn off.  After several unsuccessful attempts to fetch my lunch box, I lost patience with it.  "For heaven's sake!" I snarled as I pulled over and snared the insulated box from the passenger side floor.  

I was pleased to see Big Sweetie had packed me a piece of leftover pizza, some apricot-pecan cake, a yogurt cup, and cold water in a non-BPA bottle.  With no traffic in sight, I was free to savor this little meal by the roadside.  Nearby ox-eye daisies nodded in the breeze and I could see the jacaranda flowers were just about spent.  A bluegrass tune floated out of my CD player, ancient as the place where I stood.  

At the end of nursing school I was voted "Best at Carrying Her Lunch" which, being poor but always hungry, I did with some regularity.  This amused my wealthier classmates no end and I let them have their little joke because I wasn't about to go hungry just to impress them.  I had no idea it would prove good training for the future.  

Then I poured myself another cup of tea, checked my GPS, and pushed on, still chewing on remains of the cake.  Time and tide...and patients...wait for no man.

Peace and Quiet

Sunday is my favorite day to work.  Sunday is usually a quiet day with a lighter patient load.  I enjoy meeting visiting family members and everyone seems more relaxed.  The radio plays hours of Celtic-Blue Grass music as I drive back roads mercifully free of excess traffic.  In general, patients scheduled for a Sunday really have a need to be seen and it's always nice to be needed.    Today even the weather cooperated to put me in a cheery frame of mind.

Often clients ask me about my weekend work, as if it might be a terrible burden or something.  One recent client  remarked at length how pleased she was that a nurse had been able to visit on a Sunday.  "You don't have to work every Sunday, do you?" she asked.  "I work the weekend," I replied, "unless I'm on vacation.".  Her eyes flew open and she exclaimed, "Oh my!  Why do you do that?"  I smiled.

"You remember the old Star Trek movies?  The one where Commander Uhura says," (I put on my best no-nonsense Uhura look and continued)  'Peace and  quiet appeals to me, Lieutenant.'"

http://www.youtube.com/watch?v=_k9Ukm9LaWg

watch for it at 1:38  Happy Sunday!

Fearfully and Wonderfully Made

I was driving the back roads this morning playing The Chieftains Christmas CD, "Bells of Dublin."  (Browse here to hear their fine fiddling and piping.)  "The Bells of Dublin" gladdens the heart on a dreary December day; I truly look forward to hearing it each year. By the time I reached Heart Man's house, I was in an excellent mood and whistling an Irish tune. 

Maybe you have this conversation with your patients; the one that begins, "As we age..." and concludes with trying to get the patient to make some sensible accommodations for having grown old and frail.  Heart Man is  physically frail, but his faith has never been in better health.  He sees God in almost all persons and places.  I suspect he makes daily, even hourly, contact with the spiritually numinous; the thin places where we come close to God.  His spirit is lively and faith makes him unafraid of death.  Yet, he has a hard time living with the limitations of his body.  

How soon can I plan on going one last time to Europe?  he asks.  "Can you walk upstairs without needing oxygen?" I ask gently.  Then I review the rigors of air travel.  "Do you think you could do that without getting totally exhausted?"  Of course the answer is no; but he did so hope to go just once more. 

I have another patient, recently diagnosed with elevated triglycerides, stroke, and new hypertension, whose life and diet have suddenly, radically, changed.  It was easy for Trig Lady to maintain a heart-healthy diet when it was served from Dietary three times a day, but now that she's home she wonders what to cook, because she never was much of a cook when it came to vegetables.  And, what should she do with 8 pounds of bacon and sausage she has stored in the freezer?

Do I really have hypertension now, Trig Lady asks; I've always had a low blood pressure before. So should  I really give up the bacon?  I haven't had any for a whole week...so I shouldn't worry about eating healthy anymore.  Right?

Before this begins to read like an NCLEX test question, I should  tell you the most merciful answer is the swift and terrible one, couched as a question if possible.  To Trig Lady I said,

"With your condition/on your diet/to lower your cholesterol, you have to limit saturated fats.  That means choosing foods that give you good nutrition and less fat.  Bacon has three things you don't need/want: sat fat, sodium, and nitrates.  It doesn't have much food value (protein, vitamins) beyond that.  What breakfast foods could you eat that have good nutrition and less fat than bacon?"

Of course, even after your pep talk the patient may not do as you direct; she may talk herself into that bacon after all.  Imagine how she will go about replacing that high sat-fat with something better.  Make sure she has a plan for meals and a way to get the foods you suggest.  If that fails, you can always suggest to husband/daughter/friend that a freezer raid is in order.

It turns out Heart Man had only a vague understanding of how the circulatory system works, despite a history of  major cardiac deficits.  I learned this as I was covering normal body circulation and how cardiac deficit impairs it.

"...then the left ventricle squeezes the blood out the aorta and sends it to the whole (peripheral) body," I said, wiggling my fingers and shaking a leg to demonstrate.  Seeing his wondering face, I concluded, "It really is just like the Psalmist says, we are fearfully and wonderfully made."  

The patient gazed at me and then lit up with a smile.  "Imagine all that!" he said.  "I had no idea...to think that's how God made us.  All those blood vessels.  Praise the Lord!"   I tell you, we were having church right there in the living room.

I found myself wishing someone could make travel possible for him, all the while knowing it was a forlorn hope.  On the Prayer Team at church we learn it is our place to ask for healing in body, mind, and spirit; the rest is up to God.  Whatever God chooses, I suspect Heart Man's praise will be unceasing. Let mine be, also.

Cupcake Walking?

"...and they asked her how she liked doing Home Care and she said, 'It's a cupcake walk!'"  The Super shook her head and asked me,  "Now that you've been out there for awhile, do you agree with her?  Is Home Care a 'cupcake walk'?"

I cast my mind back over dozens of visits, the parade of faces passing in review; Mr Train Wreck, Kitty Man, Lung Lady, the Edema Twins, and their kind, concerned, families and friends.  "A cupcake walk?" I said, "Not hardly!  I don't know where or how she was practicing, but is sure wasn't here and now."

Home Health is nursing for sole proprietors-at-heart, requiring a sort of entrepreneurial spirit and a love of the open road coupled with nerves of steel and a head for infinite detail.  Add to that tolerance for reams of government paperwork and scheduling.  Bring with you a fondness for human quirks and a self-assurance that you know your patients, nursing-wise, better than anyone but God.  There you have a Home Health Nurse.

Personally, Home Health Nursing puts a smile on my face that I seldom had in Hospital Nursing.  Just being able to talk with my patients, to establish a relationship with some of them, help solve their problems, figure out where their learning deficits are and teach to the gaps in medical information, nurtures me in return.  Hospital Nursing is far more high-tech and treatment oriented, because they see medically unstable patients.  No one pays for a patient to lie in hospital unless something pretty technical is being done for him.  So, hospital nurses spend their time executing orders for Medication and Treatment in a timely manner; review plan of care, meds, labs, and imaging; manage acute problems, and chart it all accurately.   Add to that at least one patient to be admitted or discharged (another blizzard of orders) per shift, and you're lucky to get a lunch.   There is less time to talk and teach in a hospital setting.  Sometimes it's difficult even to get a bathroom break.  Maybe the Hospital Nurse of the Year is able to accomplish both technical care and talking/teaching, but the rest of us are only human.

Do not imagine--for one moment--that Home Health Nursing goes at a slower, healthier pace; it does not.  Home Health Nurses do everything Hospital Nurses do, only their patients are (at least somewhat) stable and scattered across the community.  My bulky bag is the modern equivalent of the one carried by fictional character Sue Barton, who remarked on the weight of the heavy black bag on her arm marking her as a nurse among the Henry Street patients.  My car has become my supply room.  I chart with government requirements always at the back of my mind.  I set up and change the visit schedule as necessary.   Whatever the patient needs, if I don't do it/ask for it/order it, the patient goes without.

As friend Little Mary says, "God is in the details."  If you enjoy independence, glory in nature, and have a desire to walk with patients/families through difficult times, you're going to do just fine.  That's the beauty of Home Health.

Movin' On, Movin' Back

Have I ever talked to y'all about home care nursing?  

I have done a boatload of it.  AIDS patients, IV antibiotics, TPN, dressing changes; I've done them all.  The problem was, I could never make any real money at it.   Back in the day, the only ones with steady employment were the case managers.  

I finally left field work and went into education full-time, but I have always enjoyed being on the road, making creative work of patient care.  

Home care is another breed of cat, and the first thing you notice is this: the balance of authority is different when you are on the patient's turf, instead of him being on yours.   The down side of that is, you become more a partner in wellness and less a director.  Some nurses hate that aspect of it; they also hate the travel, dislike going into strange environments, and are easily frightened by anything out of the way.  

The things I dislike about hospital nursing have to do with the lack of those stimulants!  Lord knows there is plenty to stimulate you on a given hospital shift, but seldom do the stimulants have to do with pleasant surprises.  So, when I was offered a job doing regular home care I thought it was too good to be true.

Now I'm down to the last night of 11-7.  I love the people I work with on nights; they are The Best.   We've shared some truly awesome moments.  They have helped me grow and learn to be a better nurse than I ever was before.   I can only hope to find their equal over in Home Care, but I doubt if I'm going to try.  Some things are irreplaceable.  


So, to Blondie, Mr. Somber, New Kid, and all the rest, farewell but not good bye forever.  I will miss you all.

The Year of Change

Do you ever wonder when things are going to go back to "normal," whatever you conceive that to be?  Me, too.  I thought when the threat of snow was past, things would return to Normal.  Then we had the longest hottest summer in years.  That should have taught me.  We managed to put in furnace/whole house air this year, approximately one week ahead of extreme summer heat.  Talk about cutting it close!

My youngest kid got married in May.  You know what a shambles that makes of your carefully planned routine.  It was a beautiful wedding, though.  Gave me an excuse to buy one of those snazzy imported beaded blouses.  I wrote an Irish-Scottish Blessing for the occasion and had the nerve to deliver it by way of a toast at the reception.  The bride went off in a cloud of tulle and ruching and I thought, what are we going to do for excitement now?  

I assumed things would return to Normal.  (You can see this one coming, can't you?)  What are we going to do, indeed.  Three things happened almost at once; the newlywed kid packed up hubby & household for Florida, Son's wife came down pregnant, and then the Middle Kid followed suit a month later.  "It's hardly fair" Middle Kid said, "We've only been trying for a month and I only took the pregnancy test because I was going out to eat sashimi."  Evidently the savvy Mom-to-be does not eat raw fish.  I don't think I'd know enough to be pregnant these days!  So we're coming up newlyweds and babies this year.  And that's just for starters.  

Truly, it seems that everybody I know has had a crisis or undergone some sort of change since January 1.  Every month a new thing pops up.  The Sainted Rector is retiring and the parish is somewhat agog.  A few friends' family members have died, and we're all going to miss Steven Jobs.  Although I never expected to count the newlywed kid in that number, a few friends are on the move to distant cities where there is more work than one can find in the frozen upper Midwest.  More than a few got living wage jobs, which was a real surprise blessing.  

Congress gives every indication of needing its meds adjusted; and now thousands of passionate but peaceful citizens are occupying Wall Street.  I love it.

What, I wondered, could I possibly do for an encore?  Well, I finally got serious about changing departments and at long last I have a transfer to a department where I will work when it's both daylight and when most other people are awake.  That will be a novelty.  Not that I haven't enjoyed the night shift because I have, but one day recently my brain tapped me on the shoulder and said, "Yo, Mama!  This swinging from day-awake to night-awake every week has gotta stop.  You've abused the privilege."  That's how I knew it was time.  

The other thing I am doing is getting ready to go back to college for a BSN, which shouldn't be too difficult considering I have a BA already.  Don't you love the variety of RN-to-BSN programs there are now?  LPN-to-BSN, RN-to-BSN, RN-to-MSN, RN-with-a-BA-not-in-Nursing-to-BSN, the list goes on.  I'm just grateful to have found a junior college with manageable class schedules for the 4 classes I need to enter the BSN program.  From there onward it's all online, thank the Lord.

We heard last week that Son's baby will be a girl, and we're waiting for intelligence on Middle Kid's baby next month.  Although I'm knitting blankets, don't expect me to turn into a gushy Gramma in a sweatshirt adorned with baskets of kittens.  I'm the intelligence-stimulating-book-buying Grandmama. The Grandmama who wants grandchildren to reply, "yes, Ma'am."  And, I'm having no end of fun.

I hope y'all are having fun, too.

Bad Gut Weekend

We had a 3-for-one special on GI bleeders this weekend. This offer was extended to all of the unit, not just my section, so everyone could share in the fun.  All of the bleeders were morbidly obese and helpless in the face of bloody diarrhea; all of them fractious and feeling like hammered shit.  Naturally PRBC’s and fluids were running in rivers, and lab techs appeared almost hourly to draw another round of H&H. 

There was no CNA on duty of course (no CNA was to be had for love nor money) and so another RN partially filled the role.  Brainy as we are, an RN does not have the same skills as an experienced CNA.  Having an extra nurse made it possible to actually care for the people we charge the insurer for having cared for, and I was relieved that no one’s doctor chewed out the day staff because his patient’s weight or some such was not recorded.  That was nice.  However, think what replacing a CNA with an RN does to the budget then next time you hear a call for budget cuts. 

Add to that one out of control detox patient who appeared to have returned to baseline (cursing, leaping out of bed/falling down, unable to make sense of conversation) and you have the makings of a Full Moon Weekend. Except it wasn't a full moon, it was just a weekend.

Standing Up, Speaking Out

I know two things: first, we are made in God’s image and we break one another's hearts when we forget that.  Second, all that is needed for evil to succeed is for those who see it  to stand by and say nothing.

I do racial reconciliation work.  That alone classifies me as a bleeding-heart liberal.   So be it.  I do a small part of the reconciliation work by standing with brothers and sisters of color against racism and prejudice.  As a white woman, I do most of my racial reconciliation work with whites who, like me, live lives based on the many privileges we enjoy because we are white.  Not surprisingly, it's a whole lot easier to convince white people that racism hurts people of color than to lead them toward the knowledge that racism hurts whites, too.

I do another kind of work.  As a woman who lived for many years with systemic familial abuse within my marriage, I also help other women recognize abuse.   I learned that abuse happens in every level of society, even among the rich and privileged.  Many women are afraid within their most intimate relationship and unsafe in their own homes.  

That was me.  I began this work when my own situation fell apart and I was in shock.  On that day I resolved to find my way to the truth about our marriage and family that had always been covered up.  Once I found the truth I began to tell about it and I went on talking until people I knew lined up into two camps: those who believed me and wanted what was best for me, and those who wanted to shut me up and send me back to the abusive relationship.

I have a story to tell.  It doesn't matter what others think of it.   If I can help just one woman recognize an abusive situation and successfully stand against it, I will count a lifetime of work worthwhile.   

Because it turns out the kindest women among us, the empathetic ones who hold themselves responsible when they hurt the feelings of others, are often at high risk for abuse. Abused women are not always helpless women with few options in life, but they are often women who have stopped believing in themselves.  They internalize the denigrating messages they hear in their intimate relationships.   Funny how the root of the word  applies here, isn't it?  One sort of abuse is very much like another; understand one and you begin to understand them all.

As much as I would like to think otherwise, there are people who cannot see the image of God in others; who are intentionally hurtful; whose hurting intentionally goes on behind closed doors so nobody will see and call them to account.  It is easy to become an apologist for abusive people  because they are tormented souls.  It defies comprehension to learn that abusers want the comfort, but despise the comforter.  They can’t see a single thing except their own need!  Except of course when they snap out of it for a time and show something like kindness and compassion to others;  a kindness directed almost always toward someone who will be impressed by it and expect nothing in return.   

I recall the words of Mother Teresa, who said it is hardest to love those in your own family.  It’s certainly true.  But if you or someone you love simply can’t treat a spouse with kindness and empathy, if contempt is served up with your daily meals and you walk on eggs in your own marriage…it’s time for a hard look at what’s going on.  You could be participating in an abusive relationship.

Nobody belongs in that place; I don’t believe God requires it of us.  Incredible as it seems, getting out and moving on is not the worst thing that can happen.  Wasting a lifetime serving as the scapegoat for the sins and furies of a dysfunctional partner, is.  Allowing a partner to denigrate you before the children until all respect for you is gone, is.  Pretending as if your marriage and family life is normal, and expecting the children to pretend not to see what they plainly do see, is.  If you can't do another thing, at least try to stop doing that.

Whitey Tighties & Mairzy Doats

I knew it was going to be a hysterical shift when I arrived to find the supervisor at the desk, frantically phoning for a replacement day nurse.  Within minutes, the phone--which never seemed to stop--rang again.  I was asked to take an ER report on an incoming patient.  "I haven't even clocked in!" I protested mildly.  Then the call lights started in again, and they never quit, all night long.   

I caught the squeal on the new patient.  Thanks be to God, ER had done the H&P, the off-going nurse stayed long enough to get the admitting assessment, and the patient was alert. 

The rest of the night was a blur of blood vitals and on-the-fly computer charting.  At 0600 I realized we had not had a single Code Brown.  In fact, I had found three (THREE!) patients wearing clean undies.  The one patient who did move the bowels made it to the appropriate porcelain receptacle without incident.  For our unit, this was truly astonishing.

Three of them actually slept through much of the night, but wouldn't you know the other two made up for it in spades.  IV  Lasix at 2300 is not a thing designed to produce a good night's rest.  

 

The other problem with alert patients is they are difficult to distract when you have to do something unpleasant.  This morning's patient hates injections, which are ordered q12H,  but she has that all worked out.  When the needle begins to pinch, she sings "Mairzy Doats"...out loud!  She was delighted when I sang along;  my Grandmother was quite a fan of Mairzy Doats.  I know all the words.  End of Nasty Injection Time.

Don't you think we ought to adopt Mairzy Doats as the unit theme song?

Molly & Me

I'm still in the breaking-in phase of work at Li'l Old County General.  For me, that has included finding efficient ways to do patient care and chart it without running behind.  I've solved most of the task tracking and equipment issues by developing my own version of a flow sheet and carrying a basket with med administration items.  There is (almost always) a roll of my favorite adhesive tape in there.  I couldn't do nights without my trusty penlight.  People chuckle at my blue basket, but it works.  

Now I have the latest improvement; Molly the COW.  Our unit has numerous portable laptops on Stinger bases.  These allow you to wheel the computer wherever it's needed, raise it to stand and lower it to sit while typing, it has wireless computer interface, and some have an on-board barcode scanner.  It's bulky, but the Stinger has  grown on me, because I can take it with me and chart wherever I am throughout the shift.  I can look at the patient while I chart his assessment.  I don't have to log into a new computer every time I want to chart a note or pass a med.  I don't have to go back to the desk and hope my memory will recall which arm his IV was in, or what time he developed SOB.

So I've been using the Stinger and trying to work it into my nightly routine.  The offgoing nurse frequently offers me a stationary computer "so you won't have to use a laptop," an accommodation I've taken to declining.  The nurses find my behavior mystifying.  My night colleagues get a charge out of seeing me push this thing up & down the halls, while they are tied to the desk.  

One drawback developed the other night when I brought the Stinger into a patient room, and the patient said in obvious irritation, "What the hell is that thing?"  "This," I said in my most winning tone, "is Molly the COW.  She's a Computer On Wheels."  (I made up the name on the spot.)  The patient, an alert 80-something, was singularly unimpressed but the explanation seemed to settle him down, and he allowed Molly to scan his ID band for a morning med.  I'm thinking of decking her with seasonal flowers or big stickers, to see how patients respond.  Valentine hearts coming up soon?

I especially like bringing Molly into the room for admission assessments because I can face the patient while asking 1,000 personal health questions, and chart it on the spot.  Done!  I imagine that one day we'll have the same capability in a computer the size of a Blackberry, but for now I consider Molly my best girlfriend.

Wild Ride Weekend

There was no warning, really, that this weekend was going to be wild, unless you count the number of shifts that had gone smoothly and were *almost* boring of late.  Naturally, something had to give.  

It gave an hour into the shift when the patient threw me out of their room and called for a hospital administrator.   It's the first time I've been accused of giving anyone a snippy answer.  Guess they didn't like my looks.  Their behavior became so outlandish that I had no idea what they might do next.  It turned out to be nothing but a fit of pique.  So that was a ridiculous episode; a tempest in a teapot.  After half a dozen phone calls and a supervisor visit, we traded patients and things settled down.

The second night started out with a pair of undertakers wheeling out the shrouded body of a patient who had passed at the end of the previous shift.  The patient's nurse had come on at 7, so she caught the squeal* on that one, and was looking a bit subdued.  

The night was going well, despite my several ill patients.  One was comatose, with a lot of loose chest congestion and an intermittent cough.  Another's vitals deteriorated every time they dozed off.  A third, with distention and edema, had just finished 2 units PRBC's.  I rounded often and made sure equipment was at the bedside just in case.  Then I gave a few meds and talked with the nurse whose patient had died.  

"Didn't you hear?" she said.  "I must be the angel of death.  That's the second patient that's gone out on me in a week."  "Well, you know how these things run in cycles," I said.  

We haven't had any deaths, or even very sick patients,  since New Years.  Just now we have a preponderance of very ill patients.   One of the many charms of a medical unit.  

It was now near morning.  The floor was quiet, and at that hour you can hear every sound on the floor from anywhere on the unit.  Which is how I was able to clearly hear someone call out my name, in the kind of voice that tells you something is wrong.   It wasn't a medical emergency; death is not an emergency for those who anticipate it.  The patient was simply gone from this life.  

Believe it or not, as many dying patients as I've had, I had never had one die abruptly.  This was a shock to the system.  Another visit from the supervisor.  God bless my co-workers, who prepared the patient to be seen by family, and did it before I could get off the phone with everyone who needed to be called.  The ride that night went on until a second pair of undertakers, this time wearing dark suits and overcoats, wheeled the shrouded patient away.  

We consoled one another, and stories were recounted.   The oncoming nurse, one with long experience on the unit, said she had seen seen many cases of abrupt death.  Even the float nurse had a story to tell.  I came home and had a stiff drink, and slept fitfully.

I just knew the third night was going to be either a bloody bore or something else bizarre.  I put in a foley, assessed four patients, gave two meds and two prn's for pain and then we had a minor staffing crisis.  The patient we had been told was coming from the ER did not materialize, and now we were overstaffed.  You know what that does to the budget.

So I was floated to the telemetry unit, where I had never been before.  I don't do telemetry, but after meeting Frick & Frack, the Stepdown Boys, I'm ready to learn.  I took report, did a bed check, ate some lunch sitting down, and later had time for a cup of coffee before doing a nurse lab draw and am meds.  I was actually able to sit down and eat without having a chart in my lap and a keyboard in my face!  What a great night!

*British slang meaning to take the call for an emergency.

Post-Holiday Slump

I hate the Grey Days of January & February.  We've been slow at work, too; people have been placed on-call and called off every day for the past two weeks, as if the patients themselves wanted to avoid going out.  Then it began to snow and suddenly the ER filled up and we admitted three patients overnight.  I'll never understand human behavior when it comes to hospitals and snow.  Did everyone wait to have the PNA/UTI/pancreatitis so they could be in hospital while it snowed?

The last snowstorm dumped 10-12 inches on us and the county authority is complaining bitterly about the cost of scraping and sanding the roads.  It's sleeting again so here comes more road mess.


The one bright spot has been floating to Ortho, where I was welcomed.  I found someone had created a full set of patient care protocols, which made the night go more smoothly than expected.  I actually enjoyed myself, pushing a Stinger portable computer into patient rooms to pass meds and chart assessments.  Even though it got busy at 0500, it was still a manageable shift.  I gathered some ideas I will use when back on my own unit.  Comparing my Ortho experience to the other unit, I observed how much more random detail is required on medical.   It's a wonder we ever get anything done.  When I see how far medical has to go before patient care will proceed smoothly, I am daunted. 

December 28, 2010

Last year on this day, Sweetie and I were shopping at a popular variety store in my old hometown when I got a call from the director of my Nurse Refresher program.   I had sent her an email just before Christmas, abandoning pride and throwing myself on her mercy.   

Find me a unit--anywhere--willing to take me for clinical experience, I begged.   My husband's company has been idle more than half this year and there are no projects on schedule for 2010.   I need to work!

She was not the person in charge of nurse placement, but she read my email and went to work trying to place me.   Now she was calling to tell me she had found a place for me at Li'l Old County General, 12 minutes from home; I should report the second week of January.   That phone call made my Christmas.  

A few of you may understand the chagrin I felt on visiting relatives, most of whom were healthy, happy, and well-paid while we were unemployed, broke, and putting on a good front.   I was glad for my family's success, but for me the hometown visit was too cruel a reminder of the years when we all had new clothes at Christmas, an obscene overabundance of gifts, and I was the Perfect Christmas Fairy.

2010 proved to be a year of adjustments and (Thanks be to God!) easing of financial worries.   We are in process of closing husband's company, a business into which we both put many hours of time and creative energy.   His client base has been demolished by the economy and work is so sporadic now that it doesn't make good sense to keep going.   Still, it is difficult to agree to label it DNR while there is any life left in the company.   I think at last we've agreed that "quality of life" for our company in this economy is impossible.   Pull the plug.  (sigh.)

Nursing work has made it possible for us to survive and prosper.   I didn't get a paying position until June, but Li'l Old County General has turned out to be a golden employer.  Along with decent working conditions, decent pay, and shift differential I got health insurance, sick leave, and chance for advancement.   These things are not (like husband's business) dependent on the whims of the wealthy.   Being a nurse makes it possible for me to stand on my own and provide for us while doing some earthly good.

Nobody is more surprised than I that nursing finally worked out.   Since I began in 1973, nursing seemed  an albatross of a job to me; I never felt fast enough or smart enough, and the shift work was a constant trial.   I left nursing three times, but fortunately I never lost my hard-won nurse sensibility.   The RN refresher course gave me a chance to demonstrate that my skills were not too rusted for use; forty years of varied life experience had made me a better nurse, too.

In the upcoming year I will grapple with my future in nursing; what direction will I take?  Informatics?  Chemotherapy certification?  RN to BSN to MSN?  Watch this space.

Gone to La-La Land

Apologies for months of no blog entries; Nurse Philosopher has been working a second job with Sweetie Husband which took a whole lot longer than anyone anticipated. 

We were elated when the project at La-La Land Care Center came through, failing to appreciate how it was strategically timed to fall athwart of every other plan we had for the next 60 days.  A few lessons learned: first, I'm not too old to burn the candle at both ends, but the flame meets in the middle a lot faster than it used to.  Second, I don't ever want to work in an Alzheimer's unit!  Just shoot me and send me to a place where patients don't pull on your leg while you're 4 feet up on a scaffold.  Third, when a worker doesn't show, you can call him and yell, but when you get the flu yourself, you're just SOL.  Last, I can personally attest to the reason-destroying properties of Christmas Muzak.  Work beneath a speaker pouring out Christmas drivel should be regulated by OSHA..  Heavily. 

Anyway, we send best wishes of the season to all the folks at La-La Land Care Center.  We're certain you can figure out where the gift deodorizers go.  Those small Christmas bags for the nurses contain earplugs; we hope they'll save the sanity of a nurse or two and help them cope with the continual din at La-La.  

Peace on Earth at last!

A Cast of Characters

No doubt you've noticed that patients are characters.  I have my favorites from over the years, like Hank,  an inpatient who went on to home care through an agency I worked for.  Patients are memorable for a variety of reasons, and are more likely to be remembered if they were somehow difficult to care for.  Hank was a head injury victim with altered mental status (AMS) and a persistent flat affect that made him very difficult to read.  Bunny, his devoted but high-strung wife, had depended on him for everything and tended to swoon every time it appeared he might not come home. 

In the months it took for Hank to recover from the head injury and subsequent surgeries, he progressed from being wildly confused through an episode of PE, to discharge home.  On the day we began to strongly suspect PE, Bunny demanded to know why Hank was having a new series of tests.  My simple but clinically correct answer sent her immediately over the edge.  The dismaying idea that Hank was suddenly sicker  burned like wildfire across her mind toward the thought Hank Might Not Make It Now!  She immediately got on the phone to his doctor with a thousand queries and demands, and Doc  pretty promptly got back to the floor wanting to know what idiot told her Hank's actual condition! 

Bunny was an over-imaginative hysteric, incapable of remembering the simplest directions.    Hank under optimal conditions was no prize.  After being reprimanded for informing the patient's family as I had been taught to do in nursing school, I came to dread caring for the both of them.  One night I brought Hank's hs meds and found him in bed watching tv.  As usual, he glanced at me with utter disinterest and said, "The w'm'n w'n."  Hmm?  "The woman won," he repeated.  (What woman?  What now?  Good heavens; was he experiencing dementia?  Elevated ICP?  This would just be frosting on the medical cake.)  Suddenly and to my great relief I saw that he had been watching Billie Jean King beat Bobby Riggs 3 out of 3.  Saved.

Despite all, Hank did go home.  I never cared for him at home, but the nurse who did reported great success in implementing Hank's post-hospital regimen.  She convinced Bunny that really effective home care begins with a martini before getting started.  Once the wife was calm, Hank made excellent progress.

AMS is a condition a person has to get a feel for.  I once cared for a petite, elderly lady with terminal cancer during her long, final, hospital stay.  Her one pleasure was smoking, and back in the day we allowed patients to smoke in their rooms as long as no O2 was going; the right to keep & use smoking materials was one of the last privileges to be withdrawn, and as I recall a doctor's order was necessary to do it.  One evening she asked me if I knew what "they" were planning to do with her, but when I questioned her she clammed up.  I was concerned, but later her disorientation seemed to have dissipated and I took no further action.

Her roommate was a pleasant, alert woman who had just come back from knee surgery and was bedbound  with a hemovac in place.  That night was to be my last on the unit--my transfer to another floor had come through--and when I heard screams from far down the hall after lights out I first thought it to be a farewell prank of the night staff.  Nevertheless, on approach I found eerie shadows of firelight flickering in the doorway of a patient room.  I rushed in to find the terrified knee surgery patient screaming for rescue and the elderly woman watching as if observing from a balcony while a blanket blazed nearby on her overbed table.   I called a Code Red, and floor staff appeared with looks of astonishment.  We unlocked bed wheels and pulled the nearly frantic knee patient quickly out into the hall, where she reported her roommate had intentionally lit the blanket with a cigarette lighter. 

The rest was a blur.  I recall pulling the old lady's bed away from the fire, leaving the blazing blanket for fire responders, who were pounding up the stairwell.  I checked her bedding for sparks and then pulled her bed out into the hall.  I burned my hand on the metal side rail, although it was 45 minutes before I actually felt the pain. 

Fortunately it was a small fire, despite the great mass of responders present from all over the hospital.  The hospital was run by Grey Nuns and one of the sisters who responded had psychiatric experience.  It was she who learned that the patient who started the blaze did so because she believed the hospital was to be auctioned off  tomorrow and her along with it.  The source of her AMS was found to be metastases to the brain.  I never took the things patients say quite so lightly after that...

What Do You Do With a Day Off?

What do I do on my day off?  Well, since I live at 1927 House, my day off is spent working on something.  If you visit me, you'll get an hour of being fussed over, the dog will kiss you as long as you'll tolerate it, and there will be tea in the good china at the dining room table...but if you stay longer than that, the dog will go back to sleep and you'll be put to work.  You can start anywhere, and do anything you like; this place is a handyman's dream. Like to drywall or plaster?  How do you feel about tile?  Come by next week and I'll have plumbing for the Inner Plumber in you.  I promise, the sound of a sawzall does not disturb the dog at all, so have at it!

After ridding ourselves of the Great Striped Wasp Migration of 2010, (highly recommend the Rigid contractor's vac) we went to Homely Despot and loaded the van with materials to finish our countertops.  We're covering them in Weathered Stone ("The World's First Bendable Stone" www.weathered-stone.com.) The malleable plaster and vinyl "stone" is perfect for jobs like ours because I can wrap a bullnose counter edge and I don't have to spend a month cutting tile to fit.  We'll grout, coat the whole thing with clear epoxy floor finish, and it's a wrap.  My husband, Mr. Geometry, is laying the product out on-point.  Weathered Stone is made in Fairhope AL, and is the brainchild of Sean Howard, a former paperhanger who is a friend of ours. We like to give him a plug when we can.

As I'm standing at the wall taping drywall joints, I am thinking of my favorite squirrelly patients.  Hospitals spin off their own sort of humor, the best of which is the recent "There is a fracture" cartoon.   Patients tell me all sorts of things, mostly because I haven't yet learned to flee when they start to speak.  A 90-yr-old struggled to speak after a long convalescence; I wondered about his LOC and orientation when he said tenuously, "I know the man who invented the hospital gown..."  I stopped what I was doing and looked at him.  "His name was Seymour Butts."   I blinked; then laughed.  He got me on that one!  One could also never forget the garrulous patient with lower leg cellulitis who nevertheless stumped out to the station to ask, "What is it that the more you take away from it, the bigger it gets?"  Hmmm.  You got me there, pal; what is it?  "A hole.  Gotcha!" he chortled with glee.  So glad I could make his day. 

After the patient humor, I just couldn't let a good giggle opportunity pass, so I went to the internet.
Q: How many nurses does  it take to change a light bulb?
A: Twelve: One to do it. One to chart it. Ten to write the policy and procedure. http://www.jokes.com/funny/health/doctors--nurses--lightbulbs

Vintage Nurse out.

Time On Your Hands

First of all, after several months of utter mayhem q shift, it was an unexpected surprise to find two nights in a row where I was not hideously busy.  I was busy, mind you, but not ridiculously so.  In other words, I was able to think ahead rather than react to a series of crises.  This was nice.

I even had time to do the sorts of things I do to occupy myself when things are slow, like restocking syringes and changing IV tubing.  Sure, restocking is done once a week by Central Supply, but that's small comfort if you've ever been ultra-busy and needed a saline flush STAT only to find the box empty and had to hunt for backup supply.  Restocking is a good way to get to know where supplies are, before you need them in a hurry.  I like to tidy things up, because having the med room in a shambles is to me like visual "noise" which I find very distracting.  And I contemplate pressing philosophical questions such as, why do two med rooms have a full supply of Day-of-the-Week tags, but the 3rd never does?  Night Shift Nurse remains baffled.

At about 0200 the floor went quiet; not an infusion pump beeped, no bed alarm split the silence.  Aaaah.  There is something to be said for any job that takes you away from the clamor to be endured on days and 3-11.  I made a bed check just to be sure the patients weren't getting away from me.  They were all snug in their beds; Lung Lady, the Moaner,  Mrs.NPO, BatLady, and Smiley; all snoring, the IV's infusing beautifully.  "IVF, O2, and patient safety maintained." You have to be careful with moments like these; they make you  think you've become Wonder Nurse and created the present serenity, when in fact it's pure dumb luck.

Down the hall, the staff were beguiling the time in conversation.  "Do you all follow nurse blogs?" I asked.  They looked at me blankly.  "Noooo..." they responded, after a moment to figure out what I meant by Nurse Blogs.  I wanted to tell them about Head Nurse's surgery, and how proud we all are of Crazed Nurse, and the latest ER story from Storyteller Doc, but I didn't think they'd get it.  Instead, I heard gardening and canning tips, we discussed the whereabouts of the last 3 heavy-work patients who had left, and Blondie told us an amusing story of an elderly woman so reticent that she could never bring herself to speak of her genitalia as anything but "my kittycat."  (I'm not a native; it was a new one on me.)

We looked at one another.  Our hardworking CNA heaved a sigh.  "Well, who wants to help me turn patients?"  Several of us volunteered and wandered off to the next Code Brown.  The rest returned to charting.  And so it goes...